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Charles Darwin University
Organ Transplantation in Australia
Inequities in Access and Outcome for Indigenous Australians
Lawton, Paul D.; McDonald, Stephen P.; Snelling, Paul L.; Hughes, Jaquelyne; Cass, Alan
Published in:Transplantation
DOI:10.1097/TP.0000000000001911
Published: 01/11/2017
Document VersionPeer reviewed version
Link to publication
Citation for published version (APA):Lawton, P. D., McDonald, S. P., Snelling, P. L., Hughes, J., & Cass, A. (2017). Organ Transplantation inAustralia: Inequities in Access and Outcome for Indigenous Australians. Transplantation, 101(11), e345-e346.https://doi.org/10.1097/TP.0000000000001911
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Download date: 30. May. 2020
Copyright © Wolters Kluwer Health. Unauthorized reproduction of this article is prohibited.
Transplantation Publish Ahead of PrintDOI: 10.1097/TP.0000000000001911
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Organ Transplantation in Australia: Inequities in Access and Outcome for
Indigenous Australians
Paul D. Lawton, MBBS FRACP PhD 1
Stephen P. McDonald, MBBS(Hons) FRACP PhD 2
Paul L. Snelling, MBChB BMedSci FRACP 3
Jaquelyne Hughes, BMed FRACP PhD 1,4
Alan Cass, MBBS BA FRACP PhD 1
1Menzies School of Health Research, Charles Darwin University, Darwin, Australia
2ANZDATA Registry & Royal Adelaide Hospital, Adelaide, Australia
3Statewide Renal Services, Royal Prince Alfred Hospital, Sydney, Australia
4Royal Darwin Hospital, Darwin, Australia
Correspondence information:
Paul D Lawton
Menzies School of Health Research
P.O. Box 41096
Casuarina, NT, 0811
Australia
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Authorship:
Paul Lawton and Alan Cass drafted this letter to the editor, which was reviewed and edited by
Stephen McDonald, Paul Snelling and Jaquelyne Hughes. All authors take responsibility for
the completed work.
Disclosure:
All authors have extensive experience working with Indigenous Australians with end-stage
kidney disease. The authors declare no other conflicts of interest.
Funding:
Paul Lawton is supported by a National Health and Medical Research Council (NHMRC)
Early Career Fellowship (#1120640). Jaquelyne Hughes is supported by an NHMRC Early
Career Fellowship (#1092576).
Abbreviations:
ESKD – end stage kidney disease
NHMRC – National Health and Medical Research Council of Australia
RRT – renal replacement therapy
USA – United States of America
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We agree with the authors about the successes of organ transplantation in Australia 1.
However, we would like to highlight the lack of access to kidney transplantation and
insufficient progress in maximising graft survival for Indigenous Australians.
Indigenous Australians have at least 6 times the age-standardised incidence of end-
stage kidney disease (ESKD) requiring renal replacement therapy (RRT) as non Indigenous
Australians. Among adults aged 25 to 64 and people from remote areas, rates are up to 15
times higher. Although constituting only 3.0% of the Australian population, over 1 in 10
patients commencing RRT each year in Australia are Indigenous. At the end of 2015, 1647
(13.2%) of 12 461 patients receiving dialysis treatment in Australia were Indigenous; in
contrast, only 241 (2.3%) of 10 551 patients with a functioning kidney transplant were
Indigenous 2
.
Waitlisting for deceased donor kidney transplantation is uncommon for Indigenous
patients. At the end of 2015, 1.9% of all Indigenous dialysis patients were on the waiting list,
in contrast to 9.5% of non Indigenous patients 2
. This leads to lower transplantation rates.
When all else is equal, Indigenous Australians have a quarter the chance of non Indigenous
patients of receiving a kidney transplant, with rates broadly like those in USA, Canada and
New Zealand 3
. Indigenous patients understand the potential advantages of kidney
transplantation and want access to this treatment modality, but concerns among kidney
specialists about poorer outcomes for Indigenous Australian patients compared to non
Indigenous patients appear to be a major reason for nonreferral for deceased donor waitlisting
4.
Posttransplantation outcomes for Indigenous Australians have indeed been worse than
those for non Indigenous Australians. Analysis of national registry data shows that
Indigenous kidney transplant recipients, after adjustment for age and comorbidity, had almost
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twice the risk of death of non Indigenous recipients between 2000 and 2012, and a 60%
increased chance of losing a kidney transplant. Unlike non Indigenous kidney transplant
recipients (in whom cardiac and cancer causes predominate), and in contrast with widespread
perceptions that immunosuppressive medication noncompliance is the major problem
amongst Indigenous patients4, infection has been the dominant cause of death or kidney
transplant loss.
However, in the presence of inequity in access to kidney transplantation, is it
appropriate to adopt a predominantly utilitarian approach to decisions regarding waitlisting?
Rather than comparing Indigenous and non Indigenous transplant outcomes, it would appear
fairer to compare the risks and benefits of transplant versus remaining on dialysis for
Indigenous patients.
National coordination to improve outcomes for Indigenous kidney transplant
recipients (involving shared approaches to data collection, immunosuppression, monitoring
and infection prophylaxis for the small number currently transplanted) has been suggested by
us as a stepping stone to improved access to the waiting list, but has proven challenging to
implement. The Australian transplant community has been capable of achieving incremental
but ultimately large improvements in outcome over the last 45 years. Without targeted
efforts, Australians will continue to experience 2 tiers of ESKD treatment outcomes: among
the best in the world for non Indigenous patients, and something substantially less than that
for Indigenous Australians.
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References
1. Alexander SI, Clayton PA, Chadban SJ. Organ transplantation in Australia.
Transplantation. 2017; 101(5):891-2.
2. Australia & New Zealand Dialysis & Transplant Registry. The 39th
Annual ANZDATA
Report. http://www.anzdata.org.au/v1/report_2016.html. Updated January 30, 2017.
3. Yeates KE, Cass A, Sequist TD, et al. Indigenous people in Australia, Canada, New
Zealand and the United States are less likely to receive renal transplantation. Kidney Int.
2009; 76(6):659-64.
4. Anderson K, Devitt J, Cunningham J, Preece C, Jardine M, Cass A. If you can't comply
with dialysis, how do you expect me to trust you with transplantation? Australian
nephrologists' views on Indigenous Australians' 'non-compliance' and their suitability for
kidney transplantation. Int J Equity Health. 2012; 11(21):1-14.
5. Barraclough KA, Grace BS, Lawton P, McDonald SP. Residential location and kidney
transplant outcomes in Indigenous compared with non-Indigenous Australians.
Transplantation. 2016; 100(10):2168-76.
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